Ultrasound-guided Foam Sclerotherapy
Varicose veins are a sign of underlying venous insufficiency and affect 20-30% of adults, most commonly women. Long saphenous vein insufficiency is the most common form of venous insufficiency in people presenting with symptoms. People with varicose veins often have no symptoms but may have fatigue, heaviness, aching, throbbing, itching and cramps in the legs. In some patients chronic venous insufficiency can lead to skin discoloration, inflammatory dermatitis and ulceration.
2. Indications for treatment of veins using Foam
If conservative methods such as compression stockings fail to alleviate symptoms or if improvement of the appearance is desired then definitive therapy using various minimally invasive modalities (e.g. Foam Sclerotherapy, Radiofrequency Ablation, Endovenous Laser, VenaSeal etc.) may be considered. Surgery (such as ligation or stripping) is rarely required and only if the condition is more complicated or for particularly large veins. Foam is particularly useful for anatomically complex varicose veins which is often the case when treating recurrent veins following previous surgery.
3. What does the procedure involve?
Ultrasound-guided foam sclerotherapy for varicose veins is a variation of established sclerotherapy techniques that use liquid injection. It uses a sclerosant solution that has been transformed into foam by being forcibly mixed with air or preferably, carbon dioxide plus oxygen. The latter gas combination is physiological and is completely soluble in blood and, therefore, potentially much safer than injecting foam made with air. Our research on the potential benefits of using physiological gas as opposed to air for making foam has been published (click here). Unlike the majority of centres which continue to use air-based foam, we only use physiological gas.
The procedure is performed with local anaesthesia. A catheter is inserted into the main affected superficial vein and is monitored using ultrasound imaging. At the Plymouth Vein Clinic we use sclerosant foam made using carbon dioxide plus oxygen which is then injected and monitored. Once the foam has filled the entire main superficial vein, the top end of the vein may be compressed to keep the foam in the superficial veins. The foam causes inflammation of the vein lining, clot formation inside the vein, obliteration of the vein's lumen and vein occlusion. Click here for a video of the procedure.
Further injections may be given during the same session to make sure that all the varicose veins have been completely filled. If any vein is incompletely treated, further injections can be given in a second session. In most cases a single treatment is sufficient, in about ten to fifteen percent of cases we need to repeat the treatment to deal with any remaining veins.
4. How effective is the treatment?
The National Institute for Health and Clinical Excellence (NICE) published updated guidance in February 2013. Current evidence on the efficacy and safety of ultrasound-guided foam sclerotherapy for varicose veins is adequate. Studies have shown the treatment to be successful in over 90% patients. The rate of symptomatic varicose vein recurrence ranges from 4% to 22% at 5-year follow-up. Current evidence suggests that anatomical vein closure rates may be lower with Foam Sclerotherapy than with Endothermal Ablation techniques especially for large veins, but there are no clinically important differences in patient outcomes between Foam Sclerotherapy and other treatment modalities for varicose veins in the short to medium term.
5. Are there any risks?
The potential complications of this procedure are deep vein thrombosis, thrombophlebitis and allergy. Temporary chest tightness, dry cough, headaches and visual disturbance can occur occasionally but usually resolve within minutes. Very rare but significant complications include myocardial infarction, pulmonary embolism, seizures, transient ischaemic attacks and stroke. Only a few cases of stroke have been reported in the world literature using air-based Foam but not with oxygen / carbon dioxide. All cases had complete or near complete recovery. While millions of Foam Sclerotherapy treatments have been performed world-wide, no deaths or stroke with significant after effects have been reported to date.
6. What are the side effects?
Some patients will get phlebitis where the treated veins become red, painful and tender. This may require treatment with an anti-inflammatory tablet e.g. Ibuprofen, but usually resolves spontaneously. At follow up we may aspirate trapped blood from treated veins to alleviate any lumpiness or discomfort if necessary. After a few weeks there may still remain some hard lumps and some bruising where the veins used to run, THIS IS NORMAL and will resolve, it indicates that the treatment has worked well. A small number of patients may get some residual bruises, new spider veins, blemishes or brownish pigmentation developing in the skin overlying the treated veins especially with large veins close to the skin. The latter usually fades with time but can be permanent in a very small minority of patients and is rarely a problem.